Waxing Consent Form
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you taken Accutane in the past 12 months?
*
Yes
No
Are you currently using any skin care products ? For example: retinol, Retin-A, Renova, Differin, Adapalene, retinoid, glycolic, Lactic, Salicylic acid, Cetaphil or Benzo products
*
yes
no
Have you had recent tanning bed or sun exposure?
*
yes
no
Check all medical conditions you have or have had that would cause your skin to be compromised during waxing services
*
Diabetes
Aids/HIV
Cancer
Herpes
Cold sores
Fever Blisters
Hepatitis
Varicose Veins
Eczema
Psoriasis
None of the above
I have given my esthetican a complete and full disclosure of all medical conditions, medications, and topical creams that could produce a negative outcome during waxing services. I understand that withholding any information could cause lifting of my skin.
*
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
I understand and accept all risks associated with waxing services. I understand my skin could experience redness, hives, itching, soreness and lifting.
Digital submission of this form is acceptance and agreement
Signature
*
Please verify that you are human
*
Submit
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